Full Text of HB5928 099th General Assembly
HB5928 99TH GENERAL ASSEMBLY |
| | 99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016 HB5928 Introduced , by Rep. Laura Fine SYNOPSIS AS INTRODUCED: |
| 215 ILCS 134/45.1 | | 215 ILCS 134/45.3 new | | 215 ILCS 134/45.4 new | |
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Amends the Managed Care Reform and Patient Rights Act. Applies the medical exemptions process to all entities licensed in the State to sell a policy of group or individual accident and health insurance or health benefits plan. Provides certain exceptions upon which a step therapy override will always be provided. Sets clinical review criteria that must be used to establish step therapy protocols. Effective immediately.
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| | A BILL FOR |
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| | | HB5928 | | LRB099 18441 EGJ 42817 b |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Managed Care Reform and Patient Rights Act | 5 | | is amended by changing Section 45.1 and by adding Sections 45.3 | 6 | | and 45.4 as follows: | 7 | | (215 ILCS 134/45.1) | 8 | | Sec. 45.1. Medical exceptions procedures required. | 9 | | (a) Notwithstanding any other provision of law, on or after | 10 | | the effective date of this amendatory Act of the 99th General | 11 | | Assembly, every insurer licensed in this State to sell a policy | 12 | | of group or individual accident and health insurance or a | 13 | | health benefits plan shall Every health carrier that offers a | 14 | | qualified health plan, as defined in the federal Patient | 15 | | Protection and Affordable Care Act of 2010 (Public Law | 16 | | 111-148), as amended by the federal Health Care and Education | 17 | | Reconciliation Act of 2010 (Public Law 111-152), and any | 18 | | amendments thereto, or regulations or guidance issued under | 19 | | those Acts (collectively, "the Federal Act"), directly to | 20 | | consumers in this State shall establish and maintain a medical | 21 | | exceptions process that allows covered persons or their | 22 | | authorized representatives to request any clinically | 23 | | appropriate prescription drug when (1) the drug is not covered |
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| 1 | | based on the health benefit plan's formulary; (2) the health | 2 | | benefit plan is discontinuing coverage of the drug on the | 3 | | plan's formulary for reasons other than safety or other than | 4 | | because the prescription drug has been withdrawn from the | 5 | | market by the drug's manufacturer; (3) the prescription drug | 6 | | alternatives required to be used in accordance with a step | 7 | | therapy requirement (A) has been ineffective in the treatment | 8 | | of the enrollee's disease or medical condition or, based on | 9 | | both sound clinical evidence and medical and scientific | 10 | | evidence, the known relevant physical or mental | 11 | | characteristics of the enrollee, and the known characteristics | 12 | | of the drug regimen, is likely to be ineffective or adversely | 13 | | affect the drug's effectiveness or patient compliance or (B) | 14 | | has caused or, based on sound medical evidence, is likely to | 15 | | cause an adverse reaction or harm to the enrollee; or (4) the | 16 | | number of doses available under a dose restriction for the | 17 | | prescription drug (A) has been ineffective in the treatment of | 18 | | the enrollee's disease or medical condition or (B) based on | 19 | | both sound clinical evidence and medical and scientific | 20 | | evidence, the known relevant physical and mental | 21 | | characteristics of the enrollee, and known characteristics of | 22 | | the drug regimen, is likely to be ineffective or adversely | 23 | | affect the drug's effective or patient compliance. | 24 | | (b) The health carrier's established medical exceptions | 25 | | procedures must require, at a minimum, the following: | 26 | | (1) Any request for approval of coverage made verbally |
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| 1 | | or in writing (regardless of whether made using a paper or | 2 | | electronic form or some other writing) at any time shall be | 3 | | reviewed by appropriate health care professionals. | 4 | | (2) The health carrier must, within 72 hours after | 5 | | receipt of a request made under subsection (a) of this | 6 | | Section, either approve or deny the request. In the case of | 7 | | a denial, the health carrier shall provide the covered | 8 | | person or the covered person's authorized representative | 9 | | and the covered person's prescribing provider with the | 10 | | reason for the denial, an alternative covered medication, | 11 | | if applicable, and information regarding the procedure for | 12 | | submitting an appeal to the denial. | 13 | | (3) In the case of an expedited coverage determination, | 14 | | the health carrier must either approve or deny the request | 15 | | within 24 hours after receipt of the request. In the case | 16 | | of a denial, the health carrier shall provide the covered | 17 | | person or the covered person's authorized representative | 18 | | and the covered person's prescribing provider with the | 19 | | reason for the denial, an alternative covered medication, | 20 | | if applicable, and information regarding the procedure for | 21 | | submitting an appeal to the denial. | 22 | | (c) A step therapy override determination request shall be | 23 | | expeditiously granted if: | 24 | | (1) the required prescription drug is contraindicated | 25 | | or will likely cause an adverse reaction by or physical or | 26 | | mental harm to the patient; |
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| 1 | | (2) the required prescription drug is expected to be | 2 | | ineffective based on the known relevant physical or mental | 3 | | characteristics of the patient and the known | 4 | | characteristics of the prescription drug regimen; | 5 | | (3) the patient has tried the required prescription | 6 | | drug while under their current or a previous health | 7 | | insurance or health benefit plan, or another prescription | 8 | | drug in the same pharmacologic class or with the same | 9 | | mechanism of action and such prescription drug was | 10 | | discontinued due to lack of efficacy or effectiveness, | 11 | | diminished effect, or an adverse event; | 12 | | (4) the required prescription drug is not in the best | 13 | | interest of the patient, based on medical appropriateness; | 14 | | or | 15 | | (5) the patient is stable on a prescription drug | 16 | | selected by their health care provider for the medical | 17 | | condition under consideration. | 18 | | (d) Upon the granting of an exception request, the insurer, | 19 | | health plan, utilization review organization, or other entity | 20 | | shall authorize the dispensing of and coverage for the drug | 21 | | prescribed by the enrollee's treating health care provider, | 22 | | provided the drug is a covered drug under the policy or | 23 | | contract. | 24 | | (c) Notwithstanding any other provision of this Section, | 25 | | nothing in this Section shall be interpreted or implemented in | 26 | | a manner not consistent with the Federal Act.
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| 1 | | (Source: P.A. 98-1035, eff. 8-25-14.) | 2 | | (215 ILCS 134/45.3 new) | 3 | | Sec. 45.3. Clinical review criteria used in step therapy | 4 | | protocols. Notwithstanding any other provision of law, on or | 5 | | after the effective date of this amendatory Act of the 99th | 6 | | General Assembly, every insurer licensed in this State to sell | 7 | | a policy of group or individual accident and health insurance | 8 | | or a health benefits plan shall base their clinical review | 9 | | criteria for step therapy protocols on clinical practice | 10 | | guidelines that: | 11 | | (1) recommend that the prescription drugs be taken in | 12 | | the specific sequence required by the step therapy | 13 | | protocol; | 14 | | (2) are developed and endorsed by an independent, | 15 | | multidisciplinary panel of experts not affiliated with an | 16 | | insurer, health plan or utilization review organization; | 17 | | (3) are based on high quality studies, research, and | 18 | | medical practice; | 19 | | (4) are created by an explicit and transparent process | 20 | | that: | 21 | | (A) minimizes biases and conflicts of interest; | 22 | | (B) explains the relationship between treatment | 23 | | options and outcomes; | 24 | | (C) rates the quality of the evidence supporting | 25 | | recommendations; and |
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| 1 | | (D) considers relevant patient subgroups and | 2 | | preferences; and | 3 | | (5) are continually updated through a review of new | 4 | | evidence and research. | 5 | | The Department shall adopt any rules necessary to enforce | 6 | | this Section. | 7 | | (215 ILCS 134/45.4 new) | 8 | | Sec. 45.4. Cost sharing. | 9 | | (a) Notwithstanding any other provision of law, on or after | 10 | | the effective date of this amendatory Act of the 99th General | 11 | | Assembly, every insurer licensed in this State to sell a policy | 12 | | of group or individual accident and health insurance or a | 13 | | health benefits plan shall ensure that where step therapy | 14 | | protocols are used to impose clinical prerequisites for | 15 | | coverage of prescription drugs, such drugs shall be available | 16 | | to the consumer at the preferred cost-sharing level for the | 17 | | item once the clinical prerequisites have been satisfied. | 18 | | (b) This Section shall not be construed to prevent insurers | 19 | | from using tiered copayment structures.
| 20 | | Section 99. Effective date. This Act takes effect upon | 21 | | becoming law.
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